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_ C.� SAft., OAQUIN LOCAL HEALTH DISTRIC' <br /> -0A OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.76-/0061� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued la-lb,- <br /> (Complete <br /> p-lb,-(Complete In Triplicate) <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> -d/or install the work herein described. This application is made in compliance with San Joaqu <br /> unty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> -B ADDRESS/LOCATION W_ 44 .737Le , J -t ��o . �7.� �rQ��� CENSUS TRACT <br /> ner's Name �, ] _ Phone t_-A <br /> dress ..Z 3 13 Z 2� . ra), z City <br /> ntractor's NameAD <br /> , r uhf_ Licensed )3 Phone j(o - <br /> PE OF WORK (Check): NEW WELL /—/ DEEPEN •RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / J PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /_/ <br /> -STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing <br /> -_ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout � <br /> —Disposal Other Other Information <br /> -,_Geophysical � Surface Seal Installed By: <br /> 4P INSTALLATION: Contractor Z aAe;; <br /> Type of Pump / H.P. J <br /> 4P REPLACEMENT: / IJ�State Work Done P,t_Ll 6ej <br /> '1 '.REPAIR: %J State Work Done <br /> TRUCTION OF WELL: Well Diameter Approximate Depth ` <br /> - Describe Material and Procedure <br /> iereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> `I the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> :er completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> .L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> 'ormation is ue to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> AOR TO GROU A F N INSPECTIO . <br /> tNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> - FOR DEPARTMENT USE ONLY <br /> SE I <br /> 'LIGATION ACCEPTED BY DATE <br /> _1ITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION v PHASE III/FINAL INSPECTION <br /> PECTION BY DATE TNCP9rTTnA7 nv nA� v <br />